Chronic unilateral anterior nodular scleritis with local inflammation of the ciliary body associated with the varicella-zoster virus

AIM: To analyze the etiopathogenesis, clinical features, and treatment algorithm for chronic unilateral anterior nodular scleritis with local inflammation of the ciliary body to increase medical alertness to the herpetic etiology of the disease in the absence of extraocular manifestations of herpes infection, reduce the disease duration, and increase the effectiveness of treatment.

RESULTS: Features of etiopathogenesis were analyzed. The characteristic clinical symptoms of chronic nodular scleritis, local anterior cyclitis, and pars planitis caused by the varicella-zoster virus (VZV) were described. The etiological role of VZV has been established based on high levels of VZV-IgG antibodies, presence of VZV-gE-IgG antibodies (markers of active virus replication), and effectiveness of antiherpetic therapy.

DISCUSSION: The surgical removal of a melanocytic skin nevus with skin autotransplantation in the paraorbital region of the left eye, in the zone of innervation of the first branch of the trigeminal nerve, contributed to the reactivation of the ophthalmic herpes and the development of anterior nodular scleritis of the left eye. An intensive long-term ineffective therapy with corticosteroids and antibacterial drugs in the absence of etiotropic treatment caused a chronic course of anterior nodular scleritis, spread of the inflammatory process to the ciliary body, and development of local anterior cyclitis and pars planitis of herpetic etiology in a 17-year-old child.

CONCLUSION: Maximum medical alertness and early and accurate clinical differential diagnosis between scleritis associated with immunoinflammatory rheumatic diseases and herpesvirus infections are necessary since the expansion of the range and number of anti-inflammatory drugs used in the absence of positive dynamics from their use leads to a chronic disease course, damage not only to deep layers of the sclera but also the spread of inflammation to the deeper layers of the eyeball, a decrease in visual acuity, undesirable effects of local glucocorticoid therapy, and an increase in intraocular pressure and development of cataracts. With any scleritis resistant to conventional treatment, the likelihood of a herpetic etiology of the inflammatory process and laboratory diagnosis of ophthalmic herpes should be considered. In the absence of a specialized laboratory, for etiological diagnosis, the possibility of ex juvantibus antiviral therapy should be considered. The described clinical symptoms of chronic nodular scleritis with local lesions of the ciliary body contribute to the early diagnosis of ophthalmoherpes, which allows the timely initiation of antiviral therapy with an antiherpetic effect, prevents the development of a chronic disease course, occurrence of complications, and preservation and/or restoration of visual acuity.